The Critical Role of the Electronic Health Record in Modern Emergency Medical Services

By: Eric Alper, MD; John Broach, MD; Eric Dickson, MD; Caitlin McEachern; David McManus, MD; Laurel O’Connor, MD; Gregory Volturo, MD & Stacy Weisberg, MD

The use of the electronic health record (EHR) has fundamentally reshaped the practice of medicine since the first systems were designed in the 1960s and 70s. (1,2) Yet even today, practitioners routinely struggle to get complete health records if a patient has been seen in multiple health systems, especially if their information needs to be transferred between different states or countries. (3,4) This disconnect between possibility and reality is currently playing out across the divide between prehospital and emergency department (ED) care. Most emergency medical services (EMS) agencies have some form of an EHR system, but these rarely interface in real time with hospital records, and critical data from a prehospital encounter is usually delayed in being integrated into the record of an ED and hospital encounter.(5) When it is integrated, it is often stored in an obscure space in the EHR and critical data such as laboratory values or vital signs are not integrated with hospital- acquired data. Equally, EMS services are often practicing without detailed knowledge of a patient’s medical history, allergies and critical background health information despite performing medical treatment at times of critical decompensation. (5) Just as the rise of computing power in the 1960s made these systems possible, newer technologies and standards were required to bridge this most recent gap between EMS practice and the continuation of patient care in brick-and-mortar facilities. (6)

By making versions of the health record available as mobile apps, EHRs can easily be accessed by a field provider with a secure Internet connection. The driving force to complete this transition was the need to perform more advanced care outside the hospital and to ensure that this care was being delivered safely and in alignment with the rest of the patient’s clinical course. This need became even more evident during the COVID-19 pandemic, in which an already overburdened hospital system needed to expand capacity rapidly.(7) Without time to expand the physical footprint of hospital space, alternate care sites were established and, importantly, created renewed interest in the treatment of patients at home.(8) The function of the EHR has always been to allow critical health information to travel with patients regardless of their location, and several innovations in EMS practice have necessitated that the record be available to these out-of-hospital providers.

First and foremost, EMS is increasingly providing much more advanced care in the community and establishing care for critical diagnoses prior to arrival at the ED. The more complex the care, the greater the need for easy access to patient history to ensure that accurate and appropriate care is being delivered. For example, in 2020, Worcester Emergency Medical Services (WEMS), the EMS agency of UMass Memorial Health, became the first EMS agency in Massachusetts to administer prehospital antibiotics for severe sepsis and septic shock.(9) For the sickest patients, early administration of antibiotics is critical, but without access to the patient’s record, it is nearly impossible to check for medication allergies or ensure that they are being given to the correct patient. Therefore, UMass Memorial Health first ensured that their paramedics had access to a mobile version of their health system’s EHR. This mobile app also facilitates transmission of clinical images, such as EKGs, prior to patient arrival and allows preregistration of patients so their detailed record is available in the hospital prior to their arrival in the ED. As EMS provides more sophisticated medical care for emergency patients , this type of connection and sharing of information becomes increasingly important.

Second, the role of EMS and the possibilities of home treatment are expanding rapidly. Mobile integrated healthcare (MIH) is a concept that allows paramedics, with an interdisciplinary support team including online physician medical control, to assess and treat patients in their homes and help them avoid ED visits.(10) The Massachusetts Office of Emergency Medical Services (MAOEMS) established a formal licensure process for MIH in 2018 and several programs have grown out of this effort.(11) At UMass Memorial Health, Worcester EMS runs such a program, and it depends heavily on the use of the patient’s EHR to ensure that the patient’s treatment is correct and that it is visible to the patient’s primary

The Critical Role of the Electronic Health Record in Modern Emergency Medical Services Continued care physician and care coordination teams. Afterall, the value of this type of home- based intervention is its incorporation with other outpatient care efforts.

This integration between healthcare settings becomes increasingly important as the level of service delivered increases in sophistication, necessitating ever- closer amalgamation with the health record.(12) Indeed, the Centers for Medicare and Medicaid Services (CMS) created a program to deliver complete inpatient care in the home as part of its Public Health Emergency (PHE) response to the COVID-19 pandemic. (13) Several organizations in Massachusetts have deployed Hospital at Home programs which rely on EHR data and functionality to provide complete hospital- level care for complex patients in their homes.

As more care is delivered outside of the hospital, the need for an electronic health record system that allows EMS and other disciplines to effectively access and contribute to the patient’s health record will be ever more important. Hospital capacity will continue to be a challenge, but delivering care in the home and preventing unnecessary hospital admissions is both the right thing for patients and the right thing for the healthcare system. Effective use of EHRs is and will continue to be critical to this newest shift in modern healthcare delivery. +

The authors would like to acknowledge the following individuals who have worked tirelessly to make the above referenced programs successful:

Eric Alper, MD is SVP, Chief Quality Officer / Chief Clinical Informatics Officer at UMass Memorial Health.

John Broach, MD, MPH, MBA, FACEP is Associate Professor of Emergency Medicine at UMass Chan Medical School and Director of the Division of EMS and Disaster Medicine at UMass Memorial Medical Center .

Eric W. Dickson, MD, MHCM, FACEP is President and CEO of UMass Memorial Health, and Professor of Emergency Medicine at UMass Chan Medical School.

Caitlin McEachern, PMP is Program Manager for the Hospital at Home program at UMass Memorial Health and UMass Memorial Medical Center.

David D. McManus, MD, ScM, FACC, FHRS, FAHA, FACP is Richard M. Haidack Professor and Chair, Department of Medicine, UMass Chan Medical School and UMass Memorial Health.

Laurel O’Connor, MD is Assistant Professor of Emergency Medicine in the Division of Emergency Medical Services and Disaster Medicine at UMass Chan Medical School.

Gregory A. Volturo, MD FACEP is Professor of Emergency Medicine and Medicine at UMass Chan Medical School and Richard V. Aghababian Endowed Chairman, Department of Emergency Medicine at UMass Memorial Health.

Stacy N. Weisberg, MD, MPH, FACEP, FAEMS is Professor Emergency Medicine and EMS Fellowship Director at UMass Chan Medical School, and Associate Medical Director of Worcester EMS/ Life Flight at UMass Memorial Medical Center.

References:

1. Gillum RF. From papyrus to the electronic tablet: a brief history of the clinical medical record with lessons for the digital age. Am J Med. 2013 Oct;126(10):853-7.

2. Evans RS. Electronic Health Records: Then, Now, and in the Future. Year Med Inform. 2016 May 20;Suppl 1(Suppl 1):S48-61. doi: 10.15265/IYS-2016-s006.

3. Kruse CS, Kristof C, Jones B, Mitchell E, Martinez A. Barriers to Electronic Health Record Adoption: A Systematic Literature Review. J Med Syst. 2016 Dec;40(12):252.

4. Fennelly O, Cunningham C, Grogan L, Cronin H, O’Shea C, Roche M, Lawlor F, O’Hare N. Successfully implementing a national electronic health record: a rapid umbrella review. Int J Med Inform. 2020 Dec;144:104281.

5. Martin TJ, Ranney ML, Dorroh J, Asselin N, Sarkar IN. Health Information Exchange in Emergency Medical Services. Appl Clin Inform. 2018 Oct;9(4):884-891.

6. Landman AB, Lee CH, Sasson C, Van Gelder CM, Curry LA. Prehospital electronic patient care report systems: early experiences from emergency medical services agency leaders. PLoS One. 2012;7(3):e32692.

7. Litchfield I, Shukla D, Greenfield S. Impact of COVID-19 on the digital divide: a rapid review. BMJ Open. 2021 Oct 12;11(10):e053440.

8. Mann D, Chen J, Chunara R, Testa Paul. COVID-19 transforms health care through telemedicine: Evidence from the field, J. Am. Med. Inform. Assoc. 2020 7(1132–1135).

9. Cunningham CT, Sanseverino A, Reznek M, Borges E, Beth Urhoy M, Gross K, Broach JP, O’Connor L. A pilot study of prehospital antibiotics for severe sepsis. Acad Emerg Med. 2022 Feb;29(2):231-233.

10. Thurman WA, Moczygemba LR, Tormey K, Hudzik A, Welton-Arndt L, Okoh C. A scoping review of community paramedicine: evidence and implications for interprofessional practice. J Interprof Care. 2021 Mar-Apr;35(2):229-239.

11. Massachusetts Office of Emergency Medical Services. “Learn about MIH and Community EMS.” Massachusetts Department of Public Health. < https://www.mass.gov/service-details/learn-about-mihand-community-ems>. Accessed 1 August 2022.

12. Choi BY, Blumberg C, Williams K. Mobile integrated health care and community paramedicine: an emerging emergency medical services concept. Ann Emerg Med 2016;67;361-6.

13. The Centers for Medicare and Medicaid Services. “Acute Hospital Care At Home”. The Centers for Medicare and Medicaid Services. <https://qualitynet.cms.gov/acute-hospital-care-at-home>. Accessed 1 August 2022.